Effect of Exercises on Lower Limbs & Muscles, Patients with Spinal Cord Injury-(SI)

1. Introduction

The attachments between the networks of the cervical along with the lumbosacral sections located in the spinal cord play a role in the coordinated movements of the body parts such as arms and legs (Nas et al., 2015). These regions are found to be associated with walking in normal individuals. It was observed that there is a network of neurons named “Central pattern generators (CPGs)” located in the spinal cord as well as the midbrain that play a role in the activation of the motor neurons (Nardone et al., 2017). It aids in the contractions and relaxations of the flexors and extensor muscles, consequently helping in the movement of the muscles and body parts.

It was observed that two spinal cord CPGs were found. One is in the cervical part of the upper limbs, and another one is in the lumbar sections of the lower limbs. It was found that spinal cord injury (SCI) is the injury from the sections of the foramen magnum to the cauda equina. The common reasons associated with these injuries are the injuries related to the sports or the accidents caused due to the accidents (Rayegani et al., 2011). It was also documented that despite the advancement in the techniques of the treatment, the person with injuries in the spinal cord may encounter a permanent disability. The studies showed that the movement of the muscles in one leg can lead towards the movement in another leg. This process occurs due to the inter-neuronal circuits (Thomaz et al., 2019).

The muscles work in coordination, and the activity of one muscle impacts the other as it was found that the activity of one muscle can influence the synergies within the different muscles to lead them towards the activation, and this movement can be measured as Electromyogram (EMG) (Tweedy et al., 2017). The electrical stimulators are used in the rehabilitation treatment of the muscles as this process is based on the activation of the paralysed muscles. The studies showed that there is an influence of the training and use of treadmill methods on the strengthening of muscles having injuries, particularly the SCIs (Adams and Hicks, 2011).

1.1. Research Question

The research question of the proposed study will be;

1. What will be the effects of active and passive exercises on lower limbs and strengthening of the muscles among the patients having the injuries in the spinal cord”?
2. What will be the effects of these exercises (active and passive) on athletes with SCIs?  
3. How will the impacts of exercises on the patients with SCI injuries be measured?

1.2. Research Objectives

The research objectives of the present study will be;

1. To analyse the electrical activity of the baseline among the control and intervention groups.
2. To check the effects of active as well as passive movement of the upper limbs on the muscles within the lower limbs of the intervention group.
3. To examine the electrical activity in the control group after a few hours of resting period on the lower muscles of limbs.

2. Literature Review

The research studies carried out on this aspect showed that there is an impact of the activity of one muscle to another muscle. For instance, the activity of the muscles in one leg is used to impact the activity of the muscles on the other (Cheung et al., 2019). This process is referred to as the co-activation functioning of the muscles and proceeds by the “Single neural command Signal”. It was documented in the study that exercises of one limb were used to impact the strengthening of the muscles due to the association of the movement of the legs. It was also found that the coordination between the legs is more than the coordination between the arms. The movement of the arms causes to impact positively on the activity of EMG in the leg muscles. The study reported that the injuries in the spinal cord influenced the movement of the body parts, and impacts can serve as it can result in the permanent disability of the body organs (Bravo-Esteban et al., 2013).

In another report, it was found that despite the advancement in technology, there are still cases in which the SCIs affect the movement and functioning of the body parts, restricting muscular movement. In the case of SCI, the functioning of the sensory or motor parts in the sacral segments is affected, and it results in paralysis. It was observed that in the paralysed muscles, there will be an increase of the by-products in the body that used to degrade the proteins. This process affects the kidneys and their normal functioning (Fleerkotte et al., 2014). The study presented that loss of muscle activity can result in the loss of minerals in the bones, resulting in the conditions named “Hypercalciuria” and often in “Renal failure”. In addition, it can also impact the body of the paralysed person by increasing complications such as hypotension, fractures, ulcers, vein thrombosis, and others (Sadowsky et al., 2013).

The studies showed that there are different types of treatments used to increase the activity of patients with SCIs. These treatments are often based on increasing the activation of muscles that are paralysed due to the SCIs by the use of electrical stimulators (Fisahn et al., 2016). It was reported in the research studies that the activities of electrical stimulators include the continual vibration of the muscles of the quadriceps and peroneal nerves that enhanced the activity of the spinal cord in injured patients such as athletes due to sports accidents. Another study showed that patients having SCIs can be recovered using the training of CPGs that can be done using the treadmill. There are different theories, such as the “Theory of planned behaviour” and “Social cognitive theory”, based on the fact that the increased activity of exercise among the patients with the SCIs can lead towards the improvement of the health outcomes (Field-Fote and Roach, 2011).

3. Research Methodology

3.1. Study Design

The proposed study will employ the case-control design in which the influence of the active as well as the passive exercises on the improvement of muscles activity and in enhancing the strengths among the patients of SCI will be examined.

3.2. Sampling Technique

A convenience sampling technique will be employed in the study to recruit the study participants. This method is selected based on easiness and cost-effectiveness (Etikan et al., 2016). In addition, the method will be feasible to approach the study participants, such as athletes who are getting treatment from the clinic due to injuries in the spinal cord. These study participants will be easy to get access by using this convenience sampling technique. The location of the study will be the clinic where the athletes use to visit to get treatment and consultation regarding the improvement in the health conditions.

3.3. Study Participants

The study participants will be the athletes who encountered the injuries during the sports activity. The study participants will be recruited through the survey questionnaire (Questionnaire provided in the appendix) in the clinics. The survey questionnaire will include information about age, gender, skill level, cause of the accident, type of fracture, level of the injury, receiving instructions, etc. These questions will be asked from the study participants in both the control and intervention groups. The sample size of the study will be 36, among which 18 participants will be placed in the control group, and 18 participants will be placed in the intervention group to check the effects of the exercise on the strengthening of muscles.

3.4. Experimental Procedures

This case-control study will include two groups of athletes who encountered the SCIs. One group will be the intervention group comprised of the patients (n=18) who are involved in the injuries of the spinal cord and receiving the active as well as the passive exercise. This will be compared to the control group (n=18), who are also the patients with spinal cord injuries but do not receive the active as well as the passive exercises. The study will be carried out by the recruitment of the participants in the clinic. The movement of the muscles will be examined, which involves the study of different parameters such as abduction, adduction, flexion, and extension movements. The control and intervention groups are categorised based on receiving the intervention of the exercises so that the impacts of the exercises on the strengthening of muscles and their movement can be analysed among the patients with injuries of the spinal cord.

3.5. Inclusion Criteria of the study

Those patients having injuries to the spinal cord and weakness of the lower limbs will be included in the study in both the control and intervention groups. The duration of the injuries in both the control and intervention group will be within a period of one year. The patients having the muscles inactivity due to issues other than spinal cord injuries will be excluded.

3.6. Exclusion Criteria of the study

The patients who are in the older ages will be excluded. In addition, the patients whose duration of injuries is more than one year will also be excluded from this study. Furthermore, patients with metabolic diseases as well as viral infections will be excluded from the study.

3.7. Experimental Protocols and measurement of variables

The activity of EMG in the muscles of the lower limb among the study participants with the injuries of the spinal cord will be measured in both the control and experimental group. These EMG activities will be measured after the activity as well as the passive movement of the limbs. Before inserting the needles into the skin, the skin will be cleaned using alcohol. To examine and analyse the “multi-unit action potentials (MUAP)” and the “resistance of inter-electrode”, the use of EMG electrodes will be done.  In addition, the electrode’s needles will be kept on the Tibialis anterior, Quadriceps femoris and other muscles as these are distributed in the belly of the muscles.

The “Spontaneous activity” will also be examined for each type of muscle at the resting and after the exercise. An analysis of the movement of muscles will be performed, which includes the adduction, abduction, extension, flexion, and movement of circumduction in both arms. Besides, the array of the electrodes will also be moved from one place to another with a distance of about 5 mm so that MUAP can be measured. The movement of the upper limbs will be measured and examined after the patients hold a weight of 1 to 2 kg. These movements will be measured after the movement of each muscle. Each of the study participants from the control as well as the intervention group will be examined for the above-mentioned parameters after two hours period.

3.8. Statistical Analysis

The obtained data will be entered in the sheet of MS Excel and will be further analysed using the “Statistical Package for Social Sciences (SPSS)” (Green and Salkind, 2016). The measured parameters from both the control and experimental group will be analysed using “Fisher’s Exact Test”. In addition, the movement of muscles will be examined using the analysis of Spearman Rank Correlation. The significance level will be set at p=0.05.

4. Ethical Considerations

The ethical approval will be obtained from the “Ethical review committee” of the university as well as from the head of the clinic centre. The informed consent will be obtained from each of the study participants in both the control and intervention groups. Each of the study participants will be explained the study objectives. In case the participant wants to leave the experiment in the middle of the study, he or she will be provided with an opportunity to leave the study during the trial period. The confidentiality of the study participants included in the study will be maintained. All of the study participants will be presented as anonymous.

5. Conclusion

The proposed research study will be helpful in examining the impacts of active and passive exercise on the activity of the lower limbs along with the strengthening of the muscles among patients having problems with spinal cord injury. The case-control study design will be employed, which will be helpful to compare the outcomes of the parameters in both the control and intervention groups.

References

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Bravo-Esteban, E., Taylor, J., Abián-Vicén, J., Albu, S., Simón-Martínez, C., Torricelli, D. and Gomez-Soriano, J., 2013. Impact of specific symptoms of spasticity on voluntary lower limb muscle function, gait and daily activities during subacute and chronic spinal cord injury. NeuroRehabilitation, 33(4), pp.531-543.

Cheung, E.Y.Y., Yu, K.K.K., Kwan, R.L.C., Ng, C.K.M., Chau, R.M.W. and Cheing, G.L.Y., 2019. Effect of EMG-biofeedback robotic-assisted body weight supported treadmill training on walking ability and cardiopulmonary function on people with subacute spinal cord injuries–a randomized controlled trial. BMC neurology, 19(1), p.140.

Etikan, I., Musa, S.A. and Alkassim, R.S., 2016. Comparison of convenience sampling and purposive sampling. American Journal of Theoretical and applied statistics, 5(1), pp.1-4.

Field-Fote, E.C. and Roach, K.E., 2011. Influence of a locomotor training approach on walking speed and distance in people with chronic spinal cord injury: a randomized clinical trial. Physical therapy, 91(1), pp.48-60.

Fisahn, C., Aach, M., Jansen, O., Moisi, M., Mayadev, A., Pagarigan, K.T., Dettori, J.R. and Schildhauer, T.A., 2016. The effectiveness and safety of exoskeletons as assistive and rehabilitation devices in the treatment of neurologic gait disorders in patients with spinal cord injury: a systematic review. Global spine journal, 6(8), pp.822-841.

Fleerkotte, B.M., Koopman, B., Buurke, J.H., van Asseldonk, E.H., van der Kooij, H. and Rietman, J.S., 2014. The effect of impedance-controlled robotic gait training on walking ability and quality in individuals with chronic incomplete spinal cord injury: an explorative study. Journal of neuroengineering and Rehabilitation, 11(1), p.26.

Green, S.B. and Salkind, N.J., 2016. Using SPSS for Windows and Macintosh books a la carte. Pearson.

Nardone, R., Orioli, A., Golaszewski, S., Brigo, F., Sebastianelli, L., Höller, Y., Frey, V. and Trinka, E., 2017. Passive cycling in neurorehabilitation after spinal cord injury: A review. The Journal of Spinal Cord Medicine, 40(1), pp.8-16.

Nas, K., Yazmalar, L., Şah, V., Aydın, A. and Öneş, K., 2015. Rehabilitation of spinal cord injuries. World Journal of Orthopedics, 6(1), p.8.

Rayegani, S.M., Shojaee, H., Sedighipour, L., Soroush, M.R., Baghbani, M. and Amirani, O.O.B., 2011. The effect of electrical passive cycling on spasticity in war veterans with spinal cord injury. Frontiers in neurology, 2, p.39.

Sadowsky, C.L., Hammond, E.R., Strohl, A.B., Commean, P.K., Eby, S.A., Damiano, D.L., Wingert, J.R., Bae, K.T. and McDonald, J.W., 2013. Lower extremity functional electrical stimulation cycling promotes physical and functional recovery in chronic spinal cord injury. The Journal of spinal cord medicine, 36(6), pp.623-631.

Thomaz, S.R., Cipriano Jr, G., Formiga, M.F., Fachin-Martins, E., Cipriano, G.F.B., Martins, W.R. and Cahalin, L.P., 2019. Effect of electrical stimulation on muscle atrophy and spasticity in patients with spinal cord injury–a systematic review with meta-analysis. Spinal Cord, 57(4), pp.258-266.

Tweedy, S.M., Beckman, E.M., Geraghty, T.J., Theisen, D., Perret, C., Harvey, L.A. and Vanlandewijck, Y.C., 2017. Exercise and sports science Australia (ESSA) position statement on exercise and spinal cord injury. Journal of Science and Medicine in Sport, 20(2), pp.108-115.

Appendices

Appendix 1: Questionnaire

Appendix 2: SPSS analysis